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AUTHORIZATION TO TREAT A MINOR


AUTHORIZATION TO TREAT A MINOR

DO NOT USE ALL CAPITAL LETTERS when completing this form, Please punctuate properly

Please enter "N/A" in areas of the form that do not apply

I, the undersigned Parent or Legal Guardian, of a minor (listed below), do hereby authorize and consent to any x-ray examination, anesthetic, medical or surgical diagnosis rendered under the general or special supervision of a member of the medical staff and emergency room staff licensed under the provisions of the Medicine Practice Act or a Dentist licensed under the provisions of the Dental Practice Act and on the staff of any acute general hospital holding a current license to operate a hospital from the State Department of Health Services. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required but is given to provide authority and power to render care which the aforementioned physician in the exercise of his/her best judgment may deem advisable. It is understood that efforts shall be made to contact the undersigned prior to rendering treatment to the patient, but that any of the above treatment will not be withheld if the undersigned cannot be reached.
This authorization is given pursuant to Pursuant to California Civil Code

example 123-456-7890
example 12-34-5678

PARTICIPATION IN A COMPETITIVE SPORT SUCH AS SOFTBALL CAN RESULT IN SEVERE INJURY OR DEATH.
THE PHYSICAL ACTIVITIES ARE SIMILAR TO BASEBALL
This consent shall remain in effect until August 10,2020
Signature:
Date:
 

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